Overview of FY 2023

Inpatient Data Validation Efforts

for Targeted Selected Hospitals

Alex Feilmeier, MHA

Program Manager
Value, Incentives, and Quality Reporting Center (VIQRC)
Validation Support Contractor (VSC)

July 7, 2021
 Purpose

The purpose of this webinar is to discuss the

Centers for Medicare & Medicaid Services
(CMS) inpatient chart-abstracted data validation
process as part of the Hospital Inpatient Quality
Reporting (IQR) Program fiscal year (FY) 2023
payment determination and the Hospital-
Acquired Condition (HAC) Reduction Program
FY 2023 program year.

07/07/2021 6
 Objectives

Participants will be able to:

• Understand the inpatient chart-abstracted data
validation process for FY 2023 data validation efforts.
• Identify the deadlines and associated required
activities relating to data validation.
• Submit healthcare-associated infection (HAI) validation
templates through the CMS Managed File Transfer
(MFT) application.
• Submit medical records requested by the CMS Clinical
Data Abstraction Center (CDAC).
• Receive and interpret validation results.

07/07/2021 7
 Acronyms and Abbreviations
APU annual payment update FY Fiscal Year MFTManaged File Transfer
Catheter-Associated Urinary Hospital-Acquired Methicillin-Resistant
CAUTI HAC MRSA
Tract Infection Condition Staphylococcus aureus
healthcare-associated National Healthcare
CCN CMS Certification Number HAI NHSN
infections Safety Network
Protected Health
CDAC Clinical Data Abstraction Center HQR Hospital Quality Reporting PHI
Information
Centers for Disease Control and prospective payment
CDC HSR Hospital Specific Report PPS
Prevention system
CEO Chief Executive Officer ICU intensive care unit Q quarter
Central Line-Associated Blood
CLABSI IPF inpatient psychiatric facility SEP sepsis
Stream Infection
Centers for Medicare & Medicaid inpatient prospective
CMS IPPS SO Security Official
Services payment system
CPOC clinical process of care IQR Inpatient Quality Reporting SSI Surgical Site Infection
Electronic clinical quality inpatient rehabilitation Value, Incentives, and
eCQM IRF VIQRC
measure facility Quality Reporting Center
Validation Support
EHR electronic health record LabID Laboratory Identified VSC
Contractor
ERUB upper bound of confidence interval LTCH long-term care hospital
 Background

• CMS assesses the accuracy of chart-abstracted

clinical process of care data in the Hospital IQR
Program, as well as the HAI data in HAC Reduction
Program through the validation process. CMS verifies
on a quarterly basis that hospital-abstracted data
submitted to the CMS Clinical Data Warehouse and
data submitted to the Centers for Disease Control and
Prevention’s (CDC) National Healthcare Safety Network
(NHSN) can be reproduced by a trained abstractor using
a standardized protocol.
• CMS performs a random and targeted selection of
inpatient prospective payment system (IPPS) hospitals
on an annual basis.
07/07/2021 9
 Inpatient Chart-Abstracted
Validation Quarters for FY 2023
Inpatient Chart-Abstracted Validation Quarters for
FY 2023
Third quarter 2020 (3Q 2020)
Fourth quarter 2020 (4Q 2020)

As described in the FY 2021 IPPS/Long-Term Care Hospital Prospective Payment

System (LTCH PPS) Final Rule (85 FR 58863–58864), in order to align the
quarters used for Hospital IQR Program and HAC Reduction Program data
validation, CMS finalized the use of measure data from only the third and fourth
quarters of 2020 for the FY 2023 program year. Therefore, for FY 2023 validation
efforts, CMS will use measure data from only these two quarters for both the
random and targeted validation pools.
For the FY 2024 program year and subsequent years, CMS finalized the use of
measure data from all of CY 2021 for both the HAC Reduction Program and the
Hospital IQR Program.
07/07/2021 10
 Clinical Process of Care
Measures for FY 2023
As a part of the Hospital IQR Program, CMS will validate up to eight
cases for clinical process of care measure(s) per quarter per hospital.
Cases are randomly selected from data submitted to the CMS Clinical
Data Warehouse by the hospital. For both applicable quarters of FY
2023 data validation, CMS will only validate the Sepsis (SEP) measure,
as shown below.

Clinical Process of Care Measures Validated

in Each Quarter of FY 2023
3Q 2020 Sepsis (SEP)
4Q 2020 Sepsis (SEP)

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 HAI Validation Measures
for FY 2023
HAI Measures for FY 2023
Central Line-Associated Bloodstream Infection (CLABSI)
Catheter-Associated Urinary Tract Infection (CAUTI)
Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia
Laboratory Identified (LabID) Events
Clostridium difficile Infection (CDI) Laboratory Identified (LabID) Events
Surgical Site Infection (SSI)

As a part of the HAC Reduction Program, CMS will validate up to ten candidate
HAI cases total per quarter per hospital. As described in the FY 2021 IPPS/LTCH
PPS Final Rule (85 FR 58863–58864), for FY 2023 validation efforts, CMS will
only validate HAI data for 3Q 2020 and 4Q 2020.
• Hospitals will be randomly assigned to submit quarterly either:
o CLABSI AND CAUTI validation templates
OR
o MRSA AND CDI validation templates
• All hospitals selected will be validated for SSI. (SSI cases are not submitted by validation
templates. They are selected from Medicare claims-based data submitted to CMS.)

07/07/2021 12
 Changes to Hospital Selection Process
for FY 2023 Data Validation Efforts
• As described in the FY 2019 IPPS/LTCH PPS Final Rule (83 FR
41478–41484), because the Hospital IQR Program finalized the
removal of the CDC NHSN HAI measures from its program, CMS
adopted processes to validate the CDC NHSN HAI measure data
used in the HAC Reduction Program.
• One hospital sample will be selected and used for validation for both
the clinical process of care measures under the Hospital IQR Program,
as well as the HAI measures under the HAC Reduction Program.
The sample will be randomly selected from the sampling frame that
includes all subsection (d) hospitals, but hospitals without an active
Notice of Participation will only be validated under the HAC Reduction
Program (83 FR 41479).
• The validation processes are intended to reflect, to the greatest extent
possible, the processes previously established for the Hospital IQR
Program to aid continued hospital reporting through clear and
consistent requirements.
07/07/2021 13
 Hospital Selection

• Random hospital selection

o In January 2021, 400 hospitals were selected.
• Targeted hospital selection
o In June of 2021, 200 additional hospitals were selected.
o In a typical year, CMS targets hospitals based on multiple
criteria outlined in the IPPS final rule. Many of the targeting
criteria are based on previous fiscal year validation efforts.
However, due to CMS granting unprecedented exceptions
in response to the Public Health Emergency for COVID-19,
this year’s targeting has been based solely on whether
hospitals have been selected for CMS data validation in
any of the previous three years.

07/07/2021 14
 Notification of Hospital Selection

Annually, for both the random and targeted

hospital selections:
• A news article, along with the list of selected
hospitals, is posted on the CMS QualityNet website:
https://qualitynet.cms.gov.
• A Listserve is released to notify the community
that the selection has occurred.
• An email communication from the VSC is sent directly
to the hospitals selected.

07/07/2021 15
 Notification of Selection

• Hospitals selected for validation are notified by email.

This communication is sent to the following hospital contact
types listed within the official CMS contact database:
o Chief Executive Officer (CEO) / Administrator
o Hospital IQR
o Infection Control
o CDAC Medical Records
o Quality Improvement
• The VSC monitors email communications to ensure all
hospitals are notified of selection. Any emails that bounce
back are researched, and hospital contacts are asked to
be updated in the CMS system to ensure future notifications
are received.
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 Selected Hospital List
The list of the hospitals selected for validation can be found on the inpatient
data validation resources page of the QualityNet website. To access the list:
1. Navigate to the CMS QualityNet website at https://www.qualitynet.cms.gov
2. Select [Hospitals-Inpatient]
3. Select [Data Management]
4. Select [Data Validation]
5. Select [Resources]
Direct link: https://www.qualitynet.cms.gov/inpatient/data-management/data-
validation/resources

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 Update Contact Information

• Regularly update hospital contact information to

ensure receipt of validation-related communications
and reminders.
• Hospitals may check and update contacts by sending
an email with their six-digit CMS Certification Number
(CCN)/Provider ID number to the Hospital Inpatient
Support Contractor at QRFormsSubmission@hsag.com

07/07/2021 18
 General Overview
of Validation Process
Hospitals fill out HAI validation templates for each quarter
of the fiscal year and submit those templates to the VSC
via the CMS MFT application.
• Hospitals must submit HAI validation templates before they
receive a medical records request packet.
• It is strongly recommended that each hospital always have
at least two QualityNet Security Officials (SOs).
o If you are unable to log in to the Hospital Quality Reporting
(HQR) Secure Portal, contact your hospital’s SO.
o If your SO is unable to reestablish your access, contact the
QualityNet Help Desk.

07/07/2021 19
 General Overview
of Validation Process
• After the cases for validation have been selected for the quarter
(based on HAI cases submitted on HAI validation templates, SSI
cases submitted to CMS via claims data, and clinical process of care
data submitted to the CMS Clinical Data Warehouse), the hospital
will receive a medical records request packet from the CDAC. The
request packet will be sent to the attention of “Medical Records
Director,” which will contain detailed instructions and case listings.
o The list of cases selected that hospitals receive from the CDAC will
contain requests for clinical process of care measures and HAI
measures, including SSI, to be validated.
o It typically takes a few weeks after the quarter’s HAI Validation Template
deadline for the entire sample of cases to be selected and sent out.
• The hospital has until the date listed on the quarter’s request to
send its records to the CDAC.
• Quarterly, hospitals deliver requested medical records to the CDAC,
and the CDAC then reabstracts and adjudicates the selected cases.
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 General Overview
of Validation Process

• It typically takes approximately four months after

the quarter’s submission deadline for hospitals
to receive their validation results for the quarter.
• Hospitals may submit an educational review request
within 30 days of receiving quarterly results.
Completed educational review forms must be
submitted within 30 days of the validation results
being posted on HQR Secure Portal.

07/07/2021 21
 General Overview
of Validation Process
• After all quarters of the validation fiscal year have been completed and all
results have been received, CMS calculates a total score reflecting the
reliability of the measures validated. After the educational review results are
taken into consideration, CMS computes a confidence interval around the
score. If the upper bound of this confidence interval (ERUB) is 75 percent or
higher, the hospital will pass the validation requirement; if the ERUB is below
75 percent, the hospital will fail the validation requirement. Hospitals that fail
chart-abstracted validation will also automatically be selected for validation in
the next fiscal year.
• For the first time with FY 2023 data validation efforts, the Hospital IQR
Program will calculate a confidence interval using only the clinical process of
care measure(s), and the HAC Reduction Program will calculate a separate
confidence interval using only the HAI measure(s). Additional information on
how this may affect payment determination/adjustment will be described in
greater detail later in this presentation.

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 FY 2023 Validation Template
Submission Deadlines
• Validation templates are due no later than 11:59 p.m. Pacific Time on each
associated deadline date. Validation templates may be submitted immediately
following the last day of each quarter period.
• For the entire validation fiscal year, hospitals selected randomly in January 2021
should follow the deadlines associated with the random hospitals only, and the
hospitals selected as targeted in spring 2021 should follow the deadlines for
targeted hospitals only.
Note: As described in the FY 2021 IPPS/LTCH PPS Final Rule (85 FR 58863– 58864),
for FY 2023 validation efforts, CMS will only validate HAI data for 3Q 2020 and 4Q 2020.

Targeted Selected Hospital

HAI Validation Template Due Dates
HAI Validation
Discharge Quarters
Template Deadline
3Q 2020 (July 1–September 30) July 15, 2021
4Q 2020 (October 1–December 31) August 16, 2021

07/07/2021 23
 Validation Template
Version and Location
• Use the current template version for each fiscal year only.
o Templates from previous years will be rejected.
o Do not save validation templates with a password and do not lock them.
• Current/correct validation template versions for the fiscal year
being validated are available on the inpatient Data Validation
Resources page of QualityNet.
• Direct link:
https://qualitynet.cms.gov/inpatient/data-management/data-validation/resources

07/07/2021 24
 Validation Template Tabs

• There are four tabs on each validation template:

1. Definitions
2. Template
3. NHSN Intensive Care Unit (ICU) Location
o For CLABSI and CAUTI NHSN ICU location
4. FY 2023 Submission Instructions
• Do not alter or change the original format of the
validation templates.
• Do not delete, rename, or change the order of the tabs.

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 Validation Template
Completion Tips
• Refer to the FY 2023 Validation Template User Guide and Submission
Instructions document posted on the QualityNet inpatient Data Validation
Resources page: https://qualitynet.cms.gov/inpatient/data-management/data-
validation/resources.
• Verify the correct fiscal year of the validation template is being used.
• Do not alter the original format of the validation templates.
• Review the [Definitions] tab on each validation template for direction
on filling out specific fields.
• Fill in all required fields denoted with an asterisk (*).
• Use the drop-downs provided in the templates to select valid values.
• Check all dates for accuracy.
• Submit only via CMS MFT application, as validation templates contain
Protected Health Information (PHI) and cannot be sent via email.

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 Validation Template
Completion Tips
• Verify the accuracy of the calendar quarter listed on each
validation template.
• Review all formats and dates for accuracy as specified on the
[Definitions] tab.
• Perform a quality check of data entered in this template against
data entered in NHSN; stay mindful of differing CMS and
NHSN deadlines.
• Check to ensure any cases with a separate Inpatient Rehabilitation
Facility (IRF) or Inpatient Psychiatric Facility (IPF) CCN are not
included on the template.

07/07/2021 27
 Validation Template Processing

• Feedback regarding the status of validation templates is

typically received within two business days of initial submission.
• If a processing confirmation is not received, email the
VSC at validation@telligen.com.
o Include the hospital six-digit CCN/Provider ID.
• After validation templates are processed, the submitter of the
template and the contact listed in the template’s first row will
receive a confirmation receipt email indicating one of two things:
1. Successful submission
OR
2. Errors have occurred that require attention and resubmission

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 If Validation Template
Submission Contains Errors
A hospital submitting a validation template with processing errors will
receive an email notification noting the errors to be corrected.
• Make the corrections specified in the email.
• Resubmit the file via the CMS MFT application by the submission deadline.
o Do not attach a template to the error email or this will be considered a
breach of PHI.
• Validation templates may only be resubmitted up until the quarterly deadline.
If error emails are received, these errors must be corrected and the template
must be resubmitted prior to the submission deadline. An error in the
template does not extend the submission deadline.
• When resubmitting a revised validation template, include a note in the CMS
Managed File Transfer application message indicating a revised template is
being submitted.
o Include the word Revised or Resubmission in the file name.
 012345_3QYY_FYXX_CAUTI_ValTemp_Revised.xlsx

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 Validation Templates Not Received

• At predetermined points up until the validation template deadline

each quarter, the VSC will send emails and attempt to contact any
hospitals that have not yet submitted.
• Validation templates with errors are not considered as submitted.
• If a hospital does not submit the required quarterly validation
templates to CMS by the deadline, they will be assigned
placeholder cases.
o Up to 10 placeholder cases can be assigned.
o All assigned placeholder cases are scored 0/1.
• If a hospital submits a validation template and receives an error-
notification email but does not make corrections and resubmit by
the template submission deadline, placeholder cases will also be
assigned and scored 0/1.

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 VSC Data Courtesy Checks
• The VSC performs some courtesy checks on the validation templates to
assist hospitals with submitting accurate data.
• The validation templates are used to randomly select cases for validation.
If the data are incorrect on the template, they could result in mismatches.
• If a hospital receives an email from the VSC asking for review of a
validation template due to a possible discrepancy, reply and indicate one
of the following:
o A new validation template has been submitted.
OR
o The data are accurate as submitted and no changes are needed.
• The following are examples of discrepancy checks:
o Listed CAUTI/CLABSI culture dates are not between the admit/discharge date.
o Differences in data exist on multiple rows of the template that appear
to be the same patient and same episode of care.
o Discrepancies between the two assigned template types exist where a patient
is listed on both templates, but the birth/admit date/discharge dates are
different from what appears to be the same episode of care.
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 Validation Templates Used to Select
HAI Cases for Validation
• Validation templates are not validated; they are used
to select HAI cases to be validated each quarter.
• CMS performs a random selection of cases submitted
from each validation template type submitted per
hospital being validated.
• Hospitals do not submit validation templates for
SSI cases.
• After a template submission deadline has passed,
data submitted on validation templates cannot
be changed.

07/07/2021 32
 HAI Sample Selection
• The HAI validation sample selection includes up to 10 cases per quarter.
• Up to four CLABSI cases from data on validation templates
AND
• Up to four CAUTI cases from data on validation templates
AND
• Up to two SSI cases from claims data for patients with colon
surgeries or abdominal hysterectomies

OR
• Up to four MRSA cases from data on validation templates
AND
• Up to four CDI cases from data on validation templates
AND
• Up to two SSI cases from claims data for patients with colon
surgeries or abdominal hysterectomies

• When there are not enough candidate cases for any one specific infection to meet the targeted number
of cases, CMS will select the candidate cases from other infection types to meet sample size targets.
• Requests identified from Medicare claims data may include a request for an index admission and
readmission record. When both types are requested, both records should be submitted.
07/07/2021 33
 Medical Record Request

• CDAC will send hospitals a written request to “Medical Records Director,”

using FedEx, to submit a patient medical record for each case and
candidate case that CMS selected for validation.
• It is important that the packet be routed as soon as possible to the correct
individual(s) responsible for fulfilling the request.
Note: The medical records request will be delivered to the address listed
under the CDAC MEDICAL RECORDS contact type in the official CMS
database. Hospitals may check the address and make updates to the
address by sending an email with their six-digit CCN/Provider ID to the
Hospital Inpatient Support Contractor at QRFormsSubmission@hsag.com.

07/07/2021. 34
 Medical Record Request

CMS will release a Case Selection Report to supplement this medical

records request, which will also list the cases selected for validation as
well as receipt status. This report can be accessed via the HQR Secure
Portal by a registered user. The report can take several business days
after the original request date to become available. To access the report:
1. Log in to the HQR Secure Portal at https://hqr.cms.gov/hqrng/login.
2. From the left-side navigation dashboard, select Program Reporting,
then Validation.
3. Under Program, select Inpatient.
4. Under Report, select Case Selection.
5. Under Period, select the applicable quarter.
6. Under Provider(s), select the applicable hospital(s).

07/07/2021 35
 Medical Record Request
• Hospitals are not allowed to submit records or additional
documentation after the record has been received by the
CDAC; this applies even if the wrong record is sent or if
pages are missing, or illegible, etc. The CDAC will abstract
every case with the applicable documentation that the hospital
originally sent.
• It is critical that hospitals have a process for reviewing each
of their records before they are submitted to the CDAC.
• All records should be carefully reviewed prior to submitting
them to the CDAC.
o Consider having an abstractor review your records prior to
submission, as they are most familiar with the location of the
information needed for abstraction.
o This is especially important if exporting records from an
Electronic Health Record (EHR) to ensure all necessary
information is present.
07/07/2021 36
 Medical Record Request

• Hospitals have until the date listed on the request to send their
records to the CDAC.
o Inpatient medical records must be received within 30 days of the
request date.
• For FY 2023 validation efforts, hospitals may submit medical
records on paper copy, on removable media (CD/DVD/flash drive),
or via the CMS MFT application. Detailed instructions to submit
medical records via any of these three methods are provided within
the packet delivered by CDAC.
• Additional information regarding medical records requested
by the CDAC can be found on QualityNet by clicking on the
[CDAC Information] tab on the Inpatient Data Validation
CDAC page: https://qualitynet.cms.gov/inpatient/data-
management/data-validation/cdac-info

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 Future Change to Medical Record
Submission Options
The following information does not apply to your current validation
efforts. It is included here to make you aware of a change to future
fiscal year validation processes.
CMS has finalized policy which will require the use of electronic file
submissions via the CMS MFT application:
• No longer allow the submission of paper copies of medical records or copies
on digital portable media such as CD, DVD, or flash drive.
• Hospitals will be required to submit PDF copies of medical records using
direct electronic file submission via the CMS MFT application.
This process change will go into affect beginning with Q1 of CY 2021 for
validation affecting the FY 2024 validation efforts and subsequent years.

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 Medical Record Submission
“Do’s and Don’ts”
• The document Record Submission Do’s and
Don’ts can be found on the Inpatient Data
Validation CDAC Information page of QualityNet.
o Direct link:
https://qualitynet.cms.gov/inpatient/data-
management/data-validation/cdac-info.
• This document provides tips for avoiding
medical record submission errors to the CDAC.

07/07/2021 39
 Quarterly Validation Reports

Two quarterly validation-related reports

are available on the HQR Secure Portal:
• Case Selection Report
• Case Detail Report
As CMS continues to modernize the HQR Secure Portal, data
validation reports and the hospital data display may change.

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 Case Selection Report
• The report displays the patient-identifying information pertaining to the cases
selected for validation. The cases on this report are the same cases as
outlined within the medical records request packet sent by CDAC.
• The report displays the Medical Record Request Date, the Due to CDAC
Date, and the Record Received Date (after CDAC has received the
hospital’s records).
• It could take up to 24 hours for the Record Received Date to populate.
• To verify receipt of records, contact the CDAC directly via email at
CDACHelpDesk@hcqis.org or by phone at (717) 718-1230, ext. 201.

Note: The report may appear differently than shown here.

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 Case Selection Report

Below are instructions to access the Case Selection Report in the new
HQR Secure Portal:
1. Log in to the HQR Secure Portal: https://hqr.cms.gov/
2. From the left-side navigation dashboard, select
Program Reporting. Then, select Validation.
3. Under Program, select Inpatient.
4. Under Report, select Validation Case Selection.
5. Under Period, select the applicable quarter.
6. Under Provider(s), select the applicable hospital(s).

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 Case Detail Report
• This report provides a list of all elements abstracted compared to the CDAC
reabstraction on each case and becomes available after the hospital receives
results for the quarter.
• Mismatches and the associated educational comments from CDAC are
displayed in red font.
o Case Detail Reports are not yet available. CMS is updating the new HQR platform
with reports for data validation. You will receive communication from the VSC when
these reports become available. Thank you for your patience as CMS works to
modernize the HQR platform.
o To access the Case Detail Report in the new HQR Secure Portal (when available):
1. Log in to the HQR Secure Portal at https://hqr.cms.gov/.
2. From the left-side navigation dashboard, select Program Reporting.
Then, select Validation.
3. Under Program, select Inpatient.
4. Under Report, select Validation Case Detail Report.
5. Under Period, select the applicable quarter.
6. Under Provider(s), select the applicable hospital(s).
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 Requesting an Educational Review

• If a hospital has a question or needs further clarification on a particular

outcome, the hospital may request an educational review within 30 days
of validation results being posted on the HQR Secure Portal.
• The educational review process and educational review forms can
be found on the inpatient Data Validation Educational Reviews page
of QualityNet:
https://qualitynet.cms.gov/inpatient/data-management/data-
validation/educational-reviews

07/07/2021 44
 Educational Review:
Corrected Quarterly Scores
• If a hospital requests an educational review and this review yields
incorrect CMS validation results for chart-abstracted measures, the
corrected quarterly score will be used to compute the final
confidence interval.
o Hospitals’ quarterly validation reports will not be updated to reflect
updated results.
• HAC Reduction Program: The annual confidence interval will
include the updated scores for HAI measures for all four quarters.
• Hospital IQR Program: The existing reconsideration process
will be used to dispute an unsatisfactory result for the last quarter
of validation..
Reduction Program: The annual confidence interval will include updated
In the current IPPS proposed rule, CMS has proposed to align the educational
scores for HAI for
review process measures of all If4 finalized,
both programs. quarters. all quarterly score corrections would be
used in the calculation of the confidence interval for all four quarters for HAI and
process will be used toclinical
disputeprocess of care measures.
an unsatisfactory validation result for the
last quarter of validation.
07/07/2021 45
 Confidence Interval Report
• After the educational review results are taken into consideration and
all quarterly results of the fiscal year have been completed, a
confidence interval is calculated based on the cumulative results.
• For the first time in FY 2023 validation, there will be two separate
Confidence Interval Reports:
o One is for the clinical process of care cases validated under the
Hospital IQR Program.
o One is for the HAI cases validated under the HAC Reduction Program.
• A detailed FY 2023 confidence interval document will be posted on
the Inpatient Data Validation Resources page of QualityNet.
Direct link: https://qualitynet.cms.gov/inpatient/data-
management/data-validation/resources

07/07/2021 46
 Confidence Interval Report:
Hospital IQR Program
• For the Hospital IQR Program, if the upper bound of the confidence interval
(ERUB) is 75 percent or higher, the hospital will pass the Hospital IQR
Program validation requirement. If the ERUB is below 75 percent, the
hospital will fail the Hospital IQR Program validation requirement and may
not receive the full Annual Payment Update (APU).
• Hospitals that fail chart-abstracted validation will also automatically be
selected for validation in the next fiscal year.
• For FY 2023 payment determination, the Hospital IQR Program validation
Confidence Interval Report is expected to be released around January
2022, and the APU results are expected to be released around May 2022.
• Additional information regarding APU can be found on the APU page of
the Hospital Inpatient Quality Reporting Program page of QualityNet.
Direct link: https://qualitynet.cms.gov/inpatient/iqr/apu

07/07/2021 47
 Confidence Interval Report:
HAC Reduction Program
• For the HAC Reduction Program, if the ERUB is 75 percent or higher, the hospital will
pass the HAC Reduction Program validation requirement. If the ERUB is below 75
percent, the hospital will fail the HAC Reduction Program validation requirement.
• Hospitals that fail chart-abstracted validation will also automatically be selected for
validation in the next fiscal year.
• As described in the FY 2019 IPPS/LTCH PPS Final Rule (83 FR 41481–41482), for
hospitals that fail validation, CMS will assign the maximum Winsorized z-score only
for the set of measures validated. For example, if a hospital was selected to submit
CLABSI and CAUTI Validation Templates but failed validation, that hospital will
receive the maximum Winsorized z-score for CLABSI, CAUTI, and SSI.
• For the FY 2023 program year, the HAC Reduction Program validation Confidence
Interval Report is expected to be released around January 2022, and the notification
to hospitals regarding payment adjustment via the HAC Reduction Program Hospital-
Specific Report (HSR) is expected to be released around July 2022.
• Additional information regarding HAC Reduction Program payment adjustment can
be found on the Payment page of the Hospital-Acquired Condition Reduction Program
page of QualityNet. Direct link: https://qualitynet.cms.gov/inpatient/hac/payment

07/07/2021 48
 Reconsiderations

• Within the Hospital IQR Program, if a hospital does not meet or exceed the 75
percent upper bound confidence interval threshold, the hospital will receive a
letter in late spring indicating they failed to meet the validation requirement of
the Hospital IQR Program and will be subject to a reduction of their APU.
o At that time, a hospital may request a reconsideration of its validation results. The
hospital would then provide information on the reason they are asking CMS to
reconsider their results.
• Additional information and the reconsideration request form are on QualityNet:
o Select [Hospitals – Inpatient]
o Select [Hospital Inpatient Quality Reporting (IQR) Program]
o Select the [APU] tab
o Select [APU Reconsideration] from the left-side navigation pane
o Direct link: https://qualitynet.cms.gov/inpatient/iqr/apu
• The HAC Reduction Program does not have a reconsideration process;
therefore, CMS urges hospitals to submit Educational Reviews within the
30-day timeframe of receiving their quarterly results.
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 Validation Changes Affecting
FY 2024 Validation Efforts
The following four slides include information
that does NOT affect your current FY 2023
validation efforts. They are included here to
make you aware of a change to future fiscal
year validation processes.

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 Validation Changes Affecting
FY 2024 Validation Efforts
To align data submission quarters, CMS will use Q1–Q4
data of the applicable calendar year for validation of both
chart-abstracted measures and electronic clinical quality
measures (eCQMs).
Example: Quarter Alignment Used for Validation Affecting the
FY 2024 Validation Efforts
Required Quarters of
Measures Submitted
Data for Validation
Q1 2021
Q2 2021
Chart-Abstracted Measures
Q3 2021
Q4 2021
eCQMs Q1 2021–Q4 2021
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 Validation Changes Affecting
FY 2024 Validation Efforts
Finalized proposals affecting hospital selection:
• Use one single sample of hospitals selected
through random selection and one sample of
hospitals selected using targeting criteria, for
both chart-abstracted measures and eCQMs.
• Expand targeted validation to include eCQMs,
not just chart-abstracted measures.
• Reduce number of randomly selected hospitals
from 400 to up to 200.

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 Validation Changes Affecting
FY 2024 Validation Efforts
Under the aligned validation process, any hospital selected
for validation will be expected to submit data to be validated
for both chart-abstracted clinical process of care measures,
HAIs, and eCQMs.
Validation Process
Beginning with FY 2024 Validation Efforts
Selection Process Number of Hospitals Measure type
Random Selection Up to 200 Chart-Abstracted CPOC, HAI, and eCQM
Targeted Selection Up to 200 Chart-Abstracted CPOC, HAI, and eCQM
Total: Up to 400 Chart-Abstracted CPOC, HAI, and eCQM
CPOC=clinical process of care

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 Validation Changes Affecting
FY 2024 Validation Efforts
Combining scoring processes:
• Under the Hospital IQR Program, there will be a combined score for the validation of
chart-abstracted clinical process of care and eCQM measure types, with the eCQM
portion of the combined score weighted at zero.
• HAIs will continue to be scored separately, under the HAC Reduction Program.

Finalized Process for FY 2024

Validation Efforts and Subsequent Years
Quarters of Data
Required for Validation Pass/Fail Criteria
Validation
COMBINED Process Chart-abstracted Measures:
(Chart-abstracted and At least 75% validation score
eCQM Validation): (weighted at 100%)
1Q 2021–4Q 2021
Up to 200 Random Hospitals AND
+ eCQM: Successful submission of at
Up to 200 Targeted Hospitals least 75% of requested medical records

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 Resources
• QualityNet validation resources:
o Validation fact sheet
o Current validation template versions
o Validation Template User Guide and Submission Instructions
o Confidence Interval document
o HAI abstraction manuals & Tool display documents
o Educational Review information
• To access these resources from qualitynet.cms.gov:
o Click on [Hospitals – Inpatient], [Data Management],
[Data Validation], and [Resources].
o https://qualitynet.cms.gov/inpatient/data-management/data-validation/resources
• For assistance with QualityNet (including logging into the HQR Secure
Portal), contact the QualityNet Service Center:
o Call (866) 288-8912 from 8 a.m. to 8 p.m. Eastern Time, Monday through Friday.
o Email qnetsupport@hcqis.org

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 Validation Questions

• Validation Support Contractor (VSC) email:

o validation@telligen.com
• CMS Hospital Inpatient Questions and Answers Tool:
o https://cmsqualitysupport.servicenowservices.com/qnet_qa
o When submitting a question, include the hospital
six-digit CCN/Provider ID to expedite a reply with
information specific to your hospital.

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 Overview of FY 2023 Inpatient Data Validation Efforts for
Targeted Selected Hospitals

Question & Answer Session

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 Continuing Education Approval
This program has been approved for continuing education
credit for the following boards:
• National credit
o Board of Registered Nursing (Provider #16578)
• Florida-only credit
o Board of Clinical Social Work, Marriage & Family Therapy and
Mental Health Counseling
o Board of Registered Nursing
o Board of Nursing Home Administrators
o Board of Dietetics and Nutrition Practice Council
o Board of Pharmacy
Note: To verify continuing education approval for any other state, license, or certification, please check
with your licensing or certification board.

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 Disclaimer

This presentation was current at the time of publication and/or upload onto the
Quality Reporting Center and QualityNet websites. Medicare policy changes
frequently. Any links to Medicare online source documents are for reference use
only. In the case that Medicare policy, requirements, or guidance related to this
presentation change following the date of posting, this presentation will not
necessarily reflect those changes; given that it will remain as an archived copy,
it will not be updated.
This presentation was prepared as a service to the public and is not intended
to grant rights or impose obligations. Any references or links to statutes,
regulations, and/or other policy materials included in the presentation are
provided as summary information. No material contained therein is intended to
take the place of either written laws or regulations. In the event of any conflict
between the information provided by the presentation and any information
included in any Medicare rules and/or regulations, the rules and regulations shall
govern. The specific statutes, regulations, and other interpretive materials should
be reviewed independently for a full and accurate statement of their contents.
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